Comparison of Intravascular Imaging–, Physiology‐, or Angiography‐Guided Approaches for Percutaneous Coronary Intervention: A Systematic Review and Network Meta‐Analysis

Background Despite current guidelines recommending physiology‐ and intravascular imaging–guided percutaneous coronary intervention (PCI) in specific lesion subsets, angiography‐guided PCI remains common in practice. The comparative effectiveness of these strategies remains uncertain. We aimed to compare clinical outcomes of PCI guided by intravascular imaging or physiological assessment versus conventional angiography. Methods We conducted a systematic review and network meta‐analysis of randomized controlled trials, searching PubMed and EMBASE up to May 31, 2025. Eligible studies compared at least 2 of the following 6 guidance modalities in PCI: angiography, intravascular ultrasound (IVUS), optical coherence tomography/optical frequency domain imaging, fractional flow reserve, angiography‐derived fractional flow reserve, and instantaneous wave‐free ratio. The primary outcome was trial‐defined major adverse cardiovascular events (MACEs). Hazard ratios (HRs) with 95% CIs were pooled using a frequentist random‐effects network meta‐analysis. Subgroup analyses assessed clinical presentation and guidance objectives such as decision making and procedural optimization. Results We identified 43 randomized controlled trials involving 39 291 patients. IVUS‐guided PCI (HR, 0.69 [95% CI, 0.60–0.79]), optical coherence tomography/optical frequency domain imaging‐guided PCI (HR, 0.75 [95% CI, 0.63–0.90]), and fractional flow reserve–guided PCI (HR, 0.81 [95% CI, 0.70–0.95]) were associated with a lower risk of MACEs compared with angiography‐guided PCI. Furthermore, IVUS‐guided PCI was associated with a lower risk of MACEs compared with instantaneous wave‐free ratio–guided PCI (HR, 0.74 [95% CI, 0.55–1.00]). IVUS‐guided PCI reduced the risk of MACE in both acute coronary syndrome and non‐acute coronary syndrome patients. Conclusions IVUS‐ and optical coherence tomography/optical frequency domain imaging–guided PCI were superior to angiography‐guided PCI in reducing MACEs. Among the physiology‐based approaches, only fractional flow reserve showed a clear benefit.